Medicare

Revised: April 29, 2019

Medicare Coverage

This section provides a brief overview of drug coverage and billing for Medicare and Minnesota Health Care Programs (MHCP). Always verify coverage and criteria with the Centers for Medicare and Medicaid Services (CMS) or the individual Medicare Part D plan before dispensing or billing drugs.

Medicare Part B

Commonly covered drugs

· Drugs used for immunosuppressive therapy

· Oral chemotherapy drugs

· Oral anti-emetics used for cancer patients

· Drugs used for inhalation and administered by nebulization

· Blood clotting factors

· Influenza vaccines

MHCP will pay Medicare Part B co-insurance as directed by Medicare Part B for eligible MHCP members.

Use your Point of Sale (POS) software to bill for self-administered Medicare Part B drugs using the appropriate National Drug Code (NDC). Do not bill MHCP the same day you bill Medicare. If all of your MHCP and Medicare provider information on file is correct, the Medicare claim will automatically cross over to MHCP with the payment details.

If the Medicare claim does not cross over to MHCP within six weeks, submit the bill to MHCP using the 837P professional claim found in MN–ITS. Use the appropriate Health Care Common Procedural Coding System (HCPCS) (J) code and modifiers. Report the corresponding NDC in the appropriate fields on the claim and include the Medicare determination and payment details. Refer to the MN–ITS Professional 837P User Guide for complete billing instructions

Medicare Part D

MHCP members eligible for Medicare Parts A and B (dual eligibility) must enroll in a Medicare Part D plan for prescription drug coverage. Any individual seeking assistance in enrolling in a Medicare Part D prescription drug plan should call the LinkAge Line at 1-800-333-2433.

For individuals whose Medicare Part D eligibility is determined retroactively, Part D eligibility will begin on the first of the month that the individual receives the notice of eligibility approval.

MHCP will not provide prescription drug coverage for dual eligibility for members that fail to or refuse to enroll in a Medicare Part D prescription plan. MHCP members who provide proof and use credible insurance to opt out of Medicare Part D will not be eligible for a low income subsidy.

If the member is a dual-eligible but the Medicare Part D plan cannot be verified, contact Humana at 1-800-865-8715.

Medicare Part D Excluded Drug Categories
MHCP will cover certain classes of drugs for dual eligibility, if those drugs are excluded by law from the Medicare Part D program, and if the drug or product is covered by MHCP. Refer to the NDC search to verify if the drug is covered by MHCP. Medicare Part D excludable drug categories include:

· Medications used for symptomatic relief of cough and colds

· Over the Counter (OTC) items including smoking cessation products

· Prescription vitamins and mineral products

Contact the individual Part D prescription plan with questions about denials, drugs not covered and authorization requirements. MHCP will not cover a Part D eligible drug solely because it is “non-formulary” for a particular Part D plan.

Medicare Part D copay amounts are the member’s responsibility; do not submit a bill for copay amounts to MHCP, except for qualified members of MHCP Program HH.